A few years ago, while I was at a family celebration, several people mentioned memory concerns to me.
Some were older adults concerned about the memory of their spouses. Some were adult children concerned about the memory of their parents. And a few were older adults who have noticed some slowing down of their own memory.
“But you know, nothing much that can be done at my age,” remarked one man in his eighties.
Wrong. In fact, there is a lot that can and should be done, if you notice memory or thinking changes in yourself or in another older adult. And you should do it because it ends up making a difference for brain health and quality of life.
First among them: identify medications that make brain function worse.
This is not just my personal opinion. Identifying and reducing such medications is a mainstay of geriatrics practice. Among other reasons, we do find that in some people, certain medications are causing memory loss symptoms — or other cognitive symptoms — to be worse.
And the expert authors of the National Academy of Medicine report on Cognitive Aging agree: in their Action Guide for Individuals and Families, they list “Manage your medications” among their “Top 3 actions you can take to help protect your cognitive health as you age.”
Unfortunately, many older adults are unaware of this recommendation. And I can’t tell you how often I find that seniors are taking over-the-counter or prescription medications that dampen their brain function. Sometimes it’s truly necessary but often it’s not.
What especially troubles me is that most of these older adults — and their families — have no idea that many have been linked to developing dementia, or to worsening of dementia symptoms. So it’s worth spotting them whether you are concerned about mild cognitive impairment or caring for someone with full-blown Alzheimers.
Every older adult and family should know how to optimize brain function. Avoiding problem medications — or at least using them judiciously and in the lowest doses necessary — is key to this.
And don’t give anyone a pass when they say “Oh, I’ve always taken this drug.” Younger and healthier brains experience less dysfunction from these drugs. That’s because a younger brain has more processing power and is more resilient. So drugs that aren’t such problems earlier in life often have more impact later in life. Just because you took a drug in your youth or middle years doesn’t mean it’s harmless to continue once you are older.
You should also know that most of these drugs affect balance, and may increase fall risk. So there’s a double benefit in identifying them, and minimizing them.
Below, I share the most commonly used drugs that you should look out for if you are worried about memory problems.
The Four Most Commonly Used Types of Medications That Dampen Brain Function
1. Benzodiazepines. This class of medication is often prescribed to help people sleep, or to help with anxiety. They do work well for this purpose, but they are habit-forming and have been associated with developing dementia.
- Commonly prescribed benzodiazepines include lorazepam, diazepam, temazepam, alprazolam (brand names Ativan, Valium, Restoril, and Xanax, respectively)
- For more on the risks of benzodiazepines, plus a handout clinically proven to help older adults reduce their use of these drugs, see “How You Can Help Someone Stop Ativan.”
- Note that it can be dangerous to stop benzodiazepines suddenly. These drugs should always be tapered, under medical supervision.
- Alternatives to consider:
- For insomnia, there is no easy and fast alternative. Just about all sedatives — many are listed in this post — dampen brain function. Many people can learn to sleep without drugs, but it usually takes a comprehensive effort over weeks or even months. This may involve cognitive-behavioral therapy, as well as increased exercise and other lifestyle changes. You can learn more about comprehensive insomnia treatment by getting the Insomnia Workbook (often available at the library!) or something similar.
- For anxiety, there is also no easy replacement. However, there are some drug options that affect brain function less, such as SSRIs (e.g. sertraline and citalopram, brand names Zoloft and Celexa). Cognitive behavioral therapy and mindfulness therapy also helps, if sustained.
- Even if it’s not possible to entirely stop a benzodiazepine, tapering to a lower dose will likely help brain function in the short-term.
- Other risks in aging adults:
- Benzodiazepines increase fall risk.
- These drugs sometimes are abused, especially in people with a history of substance abuse.
- Other things to keep in mind:
- If a person does develop dementia, it becomes much harder to stop these drugs. That’s because everyone has to endure some increased anxiety, agitation, and/or insomnia while the senior adjusts to tapering these drugs, and the more cognitively impaired the senior is, the harder it is on everyone. So it’s much better to find non-benzo ways to deal with anxiety and insomnia sooner, rather than later. (Don’t kick that can down the road!)
2. Non-benzodiazepine prescription sedatives. By far the most commonly used are the “z-drugs” which include zolpidem, zaleplon, and eszopiclone (brand names Ambien, Sonata, and Lunesta, respectively). These have been shown in clinical studies to impair thinking — and balance! — in the short-term.
- Some studies have linked these drugs to dementia. However we also know that developing dementia is associated with sleep problems, so the cause-effect relationship remains a little murky.
- For alternatives, see the section about insomnia above.
- Occasionally, geriatricians will try trazodone (25-50mg) as a sleep aid. It is thought to be less risky than the z-drugs or benzodiazepines. Of course, it seems to have less of a strong effect on insomnia as well.
- Other risks in aging adults:
- These drugs worsen balance and increase fall risk.
3. Anticholinergics. This group covers most over-the-counter sleeping aids, antihistamines such as Benadryl, as well as a variety of other prescription drugs. These medications have the chemical property of blocking the neurotransmitter acetylcholine. This means they have the opposite effect of an Alzheimer’s drug like donepezil (brand name Aricept), which is a cholinesterase inhibitor, meaning it inhibits the enzyme that breaks down acetylcholine.
You may have heard that “Benadryl has long-term side effects on the brain.” That’s because diphenhydramine (brand name Benadryl) is strongly anticholinergic.
A 2015 study found that greater use of anticholinergic drugs was linked to a higher chance of developing Alzheimer’s, and a 2021 Cochrane review found that these drugs may increase the risk of cognitive decline or dementia.
Drugs vary in how strong their anticholinergic activity is. Focus your energies on spotting the ones that have “high” anticholinergic activity. For a good list that classifies drugs as high or low anticholinergic activity, see here. Or, you can look up any of your medications using this handy “anticholinergic burden scale” calculator.
I reviewed the most commonly used of these drugs in this video:
I also cover them in an article here: “7 Common Brain-Slowing Anticholinergic Drugs Older Adults Should Use With Caution.” Briefly, drugs of this type to look out for include:
- Sedating antihistamines, such as diphenhydramine (brand name Benadryl).
- The “PM” versions of over-the-counter analgesics (e.g. Nyquil, Tylenol PM); the “PM” ingredient is usually a sedating antihistamine.
- Medications for overactive bladder, such as the bladder relaxants oxybutynin and tolterodine (brand names Ditropan and Detrol, respectively).
- Note that medications that relax the urethra, such as tamsulosin or terazosin (Flomax and Hytrin, respectively) are NOT anticholinergic. So they’re not risky in the same way, although they can cause orthostatic hypotension and other problems in older adults. Medications that shrink the prostate, such as finasteride (Proscar) aren’t anticholinergic either.
- Medications for vertigo, motion sickness, or nausea, such as meclizine, scopolamine, or promethazine (brand names Antivert, Scopace, and Phenergan).
- Medications for itching, such as hydroxyzine and diphenhydramine (brand names Vistaril and Benadryl).
- Muscle relaxants, such as cyclobenzaprine (brand name Flexeril).
- “Tricyclic” antidepressants, which are an older type of antidepressant which is now mainly prescribed for nerve pain, and includes amitryptiline and nortriptyline (brand names Elavil and Pamelor).
There is also one of the popular SSRI-type antidepressants that is known to be quite anticholinergic: paroxetine (brand name Paxil). For this reason, geriatricians almost never prescribe this particular anti-depressant.
For help spotting other anticholinergics, ask a pharmacist or the doctor, or check your medications with this handy “anticholinergic burden scale” calculator.
Alternatives to these drugs really depend on what they are being prescribed for. Often non-drug alternatives are available, but they may not be offered unless you ask. For example, an oral medication for itching can be replaced by a topical cream. Or the right kind of stretching can help with tight muscles.
Aside from affecting thinking, these drugs can potentially worsen balance. They also are known to cause dry mouth, dry eyes, and can worsen constipation. (Acetylcholine helps the gut keep things moving.)
4. Antipsychotics and mood-stabilizers. In older adults, these are usually prescribed to manage difficult behaviors related to Alzheimer’s and other dementias. (In a minority of aging adults, they are prescribed for serious mental illness such as schizophrenia. Mood-stabilizing drugs are also used to treat seizures.) For dementia behaviors, these drugs are often inappropriately prescribed. All antipsychotics and mood-stabilizers are sedating and dampen brain function. In older people with dementia, they’ve also been linked to a higher chance of dying.
- Commonly prescribed antipsychotics are mainly “second-generation” and include risperidone, quetiapine, olanzapine, and aripiprazole (Risperdal, Seroquel, Zyprexa, and Abilify, respectively).
- The first-generation antipsychotic haloperidol (Haldol) is still sometimes used.
- Valproate (brand name Depakote) is a commonly used mood-stabilizer.
- Alternatives to consider:
- Alternatives to these drugs should always be explored. Generally, you need to start by properly assessing what’s causing the agitation, and trying to manage that. A number of behavioral approaches can also help with difficult behaviors. For more, see this nice NPR story from March 2015. I also have an article describing behavioral approaches here: 7 Steps to Managing Difficult Dementia Behaviors (Safely & Without Medications).
- For medication alternatives, there is some scientific evidence suggesting that the SSRI citalopram may help, that cholinesterase inhibitors such as donepezil may help, and that the dementia drug memantine may help. These are usually well-tolerated so it’s often reasonable to give them a try.
- If an antipsychotics or mood-stabilizer is used, it should be as a last resort and at the lowest effective dose. This means starting with a teeny dose. However, many non-geriatrician clinicians start at much higher doses than I would.
- Other risks in older adults:
- Antipsychotics have been associated with falls. There is also an increased risk of death, as above.
- Caveat regarding discontinuing antipsychotics in people with dementia: Research has found that there is a fair risk of “relapse” (meaning agitation or psychotic symptoms getting worse) after antipsychotics are discontinued. A 2015 study of nursing home residents with dementia concluded that antipsychotic discontinuation is most likely to succeed if it’s combined with adding more social interventions and also exercise.
- You can learn more about medications to treat dementia behaviors in this article: “5 Types of Medication Used to Treat Difficult Dementia Behaviors“
A Fifth Type of Medication That Affects Brain Function
Opioid pain medications. Unlike the other drugs mentioned above, opioids (other than tramadol and meperidine) are not on the Beer’s list of medications that older adults should avoid. That said, they do seem to dampen thinking abilities a bit, even in long-term users. (With time and regular use, people develop tolerance so they are less drowsy, but seems there can still be an effect on thinking.) As far as I know, opioids are not thought to accelerate long-term cognitive decline.
- Commonly prescribed opiates include hydrocodone, oxycodone, morphine, codeine, methadone, hydromorphone, and fentanyl. (Brand names depend on the formulation and on whether the drug is mixed with acetaminophen.)
- Tramadol (brand name Ultram) is a weaker opiate with weaker prescribing controls.
- Many geriatricians consider it more problematic than the classic Schedule II opiates listed above, as it interacts with a lot of medications and still affects brain function. It’s a “dirty drug,” as one of my friends likes to say.
- Alternatives depend on what type of pain is present. Generally, if people are taking opiates then they have pain that needs to be treated. However, a thoughtful holistic approach to pain often enables a person to get by with less medication, which can improve thinking abilities.
- For people who have moderate or severe dementia, it’s important to know that untreated pain can worsen their thinking. So sometimes a low dose of opiate medication does end up improving their thinking.
- Other risks in older adults:
- There is some risk of developing a problematic addiction, especially if there’s a prior history of substance abuse. But in my experience, having someone else — usually younger — steal or use the drugs is a more likely problem.
Where to Learn About Other Drugs That Affect Brain Function
Many other drugs that affect brain function, but they are either not used as often as the ones above, or seem to affect a minority of older adults.
Notably, there has been a lot of concern in the media about statins, but a meta-analysis published in 2015 could not confirm an association between statin use and increased cognitive impairment. In fact, a 2016 study found that statin use was associated with a lower risk of developing Alzheimer’s disease.
This is not to say that statins aren’t overprescribed or riskier than we used to think. And it’s also quite possible that some people do have their thinking affected by statins. But if you are trying to eliminate medications that dampen brain function, I would recommend you focus on the ones I listed above first.
For a comprehensive list of medications identified as risky by the experts at the American Geriatrics Society, be sure to review the 2019 Beers Criteria.
You can also learn more about medications that increase fall risk in this article: 10 Types of Medications to Review if You’re Concerned About Falling.
What to Do if You or Your Relative Is On These Medications
So what should you do if you discover that your older relative — or you yourself — are taking some of these medications?
If it’s an over-the-counter anticholinergic, you can just stop it. Allergies can be treated with non-sedating antihistamines like loratadine (brand name Claritin), or you can ask the doctor about a nasal steroid spray. “PM” painkillers can be replaced by the non-PM version, and remember that the safest OTC analgesic for older adults is acetaminophen (Tylenol).
If you are taking an over-the-counter sleep aid, it contains a sedating antihistamine and those are strongly anticholinergic. You can just stop an OTC sleep aid, but in the short term, insomnia often gets worse. So you’ll need to address the insomnia with non-drug techniques. (See here for more: 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia.)
You should also discuss any insomnia or sleep problems with your doctors — it’s important to rule out pain and serious medical problems as a cause of insomnia — but be careful: many of them will prescribe a sleeping pill, because they haven’t trained in geriatrics and they under-estimate the risks of these drugs.
If one or more of the medications above has been prescribed, don’t stop without first consulting with a health professional. You’ll want to make an appointment soon, to review the reasons that the medication was prescribed, alternative options for treating the problem, and then work out a plan to reduce or eliminate the drug.
I explain how to find a geriatric doctor near you here: How to find a geriatrician — or a medication review — near you.
To prepare for the appointment, try going through the five steps I describe in this article: “How to Review Medications for Safety & Appropriateness.”
I also recommend reviewing HealthinAging.org’s guide, “What to Ask Your Health Provider if a Medication You Take is Listed in the Beers Criteria.”
Remember, when it comes to maintaining independence and quality of life, nothing is more important than optimizing brain function.
We can’t turn back the clock and not all brain changes are reversible. But by spotting problem medications and reducing them whenever possible, we can help older adults think their best.
Now go check out those medication bottles, and let me know what you find!
We are at 200+ comments, so comments on this post have been closed. If you have a question about your medications, we recommend consulting with your usual health provider or discussing with a pharmacist.
Sheila Callaghan says
I haven’t reviewed all the comments on this topic, but wish to submit my experience with Trazodone. It was prescribed a couple of months ago to deal with a bout of severe insomnia, combined with depression, due to a family situation. I don’t like to take prescription drugs, but I was desperate. The first few days were promising. Traz broke the cycle of insomnia, but the effect didn’t last more than a few days. Then I was back to sleeping for a couple of hours, then awake for a while, repeatedly through the night. The most difficult side effect of Traz is that it almost completely wipes out my memory! I mostly quit taking it, but will occasionally take 1/2 tab if I really wish to sleep well, but then I encounter situations, such as at work, where I can’t remember something I did just the day before. I don’t trust this drug, and based on my experience, physicians should also not be so trusting in the hype the manufacturers are spreading. My doctor said repeatedly that this was a safe medication. i don’t think so. I like to know what I did yesterday. From my experience, Trazodone doesn’t let me.
Leslie Kernisan, MD MPH says
Thanks for sharing your story. Many geriatricians do prescribe trazodone on occasion, it is considered less risky than other medications and seems to be fairly well tolerated by most people. For instance, in this study of trazodone in people with Alzheimer’s, trazodone did not appear to affect results on a short cognitive test.
That said, everyone is an individual and even when a drug seems to be “well-tolerated” by most, there is often a minority that seems particularly sensitive or experiences more side-effects than most. Sounds like you’ve learned this drug doesn’t work well for you. Good luck!
Gerri Rea says
I find that drinking a concentrated form of good quality chamomile tea is very effective for me in helping me fall asleep both at bedtime and when I wake up during the night. I’m concerned about the long term use of this practice and would like your comments.
Leslie Kernisan, MD MPH says
Chamomile tea sounds quite safe and I’m not aware of any concerns. Great that you’ve found something that helps you sleep, much safer than using prescription or over-the-counter drugs for this purpose!
I take 1/2 of a 25 ml of Hydroxyzine to fall asleep once in awhile, maybe once every 2 months. I know its not alot but I always worry about dimentia. Should I be concerned taking this small amount?
Is there a safer med that helps for falling asleep?
Leslie Kernisan, MD MPH says
A half-tablet of hydroxyzine every 2 months does not sound like a lot to me, and may not be worth worrying about. That said, there are other options you could consider, to address sleep issues. I cover the safer insomnia treatment here: 5 Top Causes of Sleep Problems in Aging, & Proven Ways to Treat Insomnia.
I am 37 and recently paralyzed and am taking Lyrica and Gabapentin for nerve pain and Oxybutanin and Myrbitique for bladder issues. All four have memory loss as a potential side effect. I feel like I have noticed a significant decrease in mental capacity in the last year. This was in tandem with an increases and more stressful workload, so I am not sure what the main factor is medication or stress (or both). That said, should I be worried if any side effects of these medications could be non-reversible? I am trying to taper and swap out medications, but it is easier said than done.
Leslie Kernisan, MD MPH says
So sorry to hear of your recent paralysis. I’m afraid I don’t have any clinical experience or special training in addressing memory concerns for people your age. In general, we have more research data linking cumulative use of anticholinergics (such as oxybutynin) to eventual memory issues.
It may make sense to stabilize your health and pain right now, and then later work on a more comprehensive approach to managing your health issues without (or with minimum doses) of medication. There often are non-drug options to treat chronic pain, but they can take some time and effort to implement.
You might also want to look for an online community of people with paralysis and related issues, to get moral support and ideas on how to minimize your use of medications that affect your brain function. Good luck!
I wrote to you in February about my mother. She is 92, and is in a nursing with dementia. I was concerned about an interaction between valium and omeprazole. You weren’t aware of such an interaction, and said to check with a pharmacist. According to her pharmacist, though there is not a major interaction, the omeprazole could make it take longer for the valium to break down in her system. She is exhausted all the time. Yesterday my father and the nurse could not wake her up after her afternoon nap. Is this something to be concerned about? Since she caught a cold over a week and a half ago she hasn’t wanted to eat. She says her mouth and throat are sore, and the food tastes horrible. All she wants are cold liquids. It seems that she is getting worse. She is now having trouble swallowing her pills, and sometimes getting out words, Maybe it is just a question of the dementia progressing, but I want to have her evaluated to make sure she is not overmedicated. It doesn’t seem normal if you can’t wake someone up. What kind of doctor can do this. A neurologist? We are not happy with her primary doctor, but haven’t found anyone better yet. Thank you for your help.
Leslie Kernisan, MD MPH says
Sorry for the very delayed reply, this one slipped past me. I hope she is better by now? Being sedated or groggy could be due to the valium lasting longer in her system, but I wouldn’t expect it to cause the sore mouth and bad tasting food. You are right that it is not normal to not be able to wake her up as easily as before. For new exhaustion or difficulty arousing someone, I would generally recommend getting seen by urgent care before considering a specialty consult. Good luck and take care!
Hi, thank you for this valuable information. I came across your article/website when I was looking for information on the long-term effects of antihistamine use. I am a 32 year-old woman who has been suffering from severe insomnia now for 6 years. The problem started when I began my graduate studies. The program is very stressful. (I also have Generalized Anxiety Disorder. I have been on many different medications through the years to treat my GAD… I could go on for pages. Basically, the benzodiazepine medications work the best for me because they also help with the nausea and vomiting that go along with my anxiety.) When the insomnia problem started, I was put on Xanax to treat both the insomnia and the GAD. The Xanax knocked me out, but I would wake up with panic attacks because the Xanax has such a short half-life. I was using antihistamines as well to help me sleep. I was switched over to Ativan, which didn’t help much at all, and then they put me back on Klonopin (which I took several years prior to that for anxiety). The Klonopin helped with anxiety but not with sleep.
I started seeing a new doctor because the other doctor was not taking my concerns seriously and didn’t believe me that I could only sleep for 2 hours per night no matter what I did. The new doctor raised my Klonopin dose and also tried me on Phenobarbital and Butisol. The increased Klonopin dose is what seemed to help the most while having the fewest side effects. So I still take that along with an antihistamine to fall asleep. Sometimes I skip the Klonopin and just take an antihistamine and some all-natural sleep supplements from a health foods store.
Anyhow, I saw a naturopathic doctor last summer who did some bloodwork to finally get to the root of the insomnia issue. As it turns out, I have high estrogen, high progesterone, and slightly high cortisol- all of which either cause or contribute to the insomnia. I’ve been taking all-natural supplements to heal my adrenal glands and to lower the hormone levels (a comprehensive adrenal support supplement, Magnesium, Milk Thistle, Flax Seed, etc.) I also added some antioxidant supplements, fish oil, and MCT oil. The adrenal support supplement has helped me the most with the insomnia problem. I think if my adrenal glands are able to heal, then the insomnia and anxiety are greatly reduced.
Despite my progress, I’m still at a point now though where I need at least an antihistamine to help me fall asleep. I’d rather risk having dementia when I’m older than sacrifice my quality of life now (and never even have the chance at having a fulfilling life). I’ve had to basically put my life on hold to deal with the insomnia issue (I am not working or going to school at the moment). Along with this though comes other stressors, i.e., financial concerns from not having a steady paycheck coming in.
After hearing my story, what are your thoughts/ what would you recommend?
Does taking fish oil and other brain-protectants offset the long-term negative effects of antihistamines and benzodiazepines?
Leslie Kernisan, MD MPH says
So in general, I can’t comment much when it comes to the health problems of people your age, because it’s not where my training and experience lie.
I don’t think it’s known whether fish oil and other supplements can offset the negative effects of medications. Also, eating the right type of whole foods seems generally to lead to better outcomes than eating just an extract via a supplement. So, especially if you think you need to take medication to address your sleep issues, all the more reason to really try to eat a diet that is good for the brain.
I recently read Brain Food: The Surprising Science of Eating for Cognitive Power, by Lisa Mosconi PhD, who is associate director of the Alzheimer’s Prevention Clinic at Weill Cornell Medical College. This is a good resource if you want to use diet to help your brain remain resilient.
Thank you so much for taking the time to give me your feedback and for that important information! I am going to make more of an effort to follow a diet that is helpful for the brain. The book you linked to me seems like an excellent way to start.
Thank you for this comprehensive list. I was wondering about Sudafed and any brain function affects regarding dimentia/Alzheimers? I have been taking Sudafed 12 hour so I can sleep with terrible nasal congestion from terrible cold. I also would like advice on med. for my 89 yr old mom with Nasal congestion and cough. Sounds like Benadryl & Nyquil are out! Thank you in advance!
Leslie Kernisan, MD MPH says
Sudafed (pseudoephedrine) is not usually considered concerning for brain function, unless it’s also combined with diphenhydramine (brand name benadryl) or some other type of over-the-counter anticholinergic sedative.
Yes, in geriatrics we would usually try to avoid Benadryl and Nyquil. You could ask your mother’s doctor about trying something like Sudafed for nasal congestion; it should be considered in light of her medical history. Good luck!
I have to disagree with the Trazodone. While Z-drugs have their negative side effects and interactions, has anyone seen the list of interactions and side effects for trazodone? And who shouldnt take it? 213 major drug interactions. 812 moderate interactions. Every possible side effect from nausea to chest pain and priapism. I took wellbutrin, metropolol, flomax daily. And zofran 4 to 5 times a week for nausea started taking the zofran 8 times a week to keep my food down after the trazodone. Started getting sicker, chest pains every day, uneven heartbeats, fainting spells. All the while it gave me long but unsatisfying sleep. Upped the dose to 100 mg. Got even worse, turns out all the meds i take had major interactions with trazodone. Someone should have looked it up. Also if its not recomended for people with heart disease either. It has so many warning labels, and a list of interactions a pharmacist couldnt remember to tell me. So how is it prescribed like candy but the safer Z drugs and antipsychotics are treated like poison when its clearly the opposite? Only way i even found out about serotonin syndrom, hypotention and the risk to my existing heart condition was a psychiatrist who put the pieces together.
Leslie Kernisan, MD MPH says
Many medications have long lists of interactions if one looks them up. There are certainly some individuals who respond poorly to trazodone and no prescription sedative should be considered 100% safe.
I have linked to reputable resources about trazodone in other comments. Also, the American Geriatrics Society has recently released the 2019 update of the “Beers Criteria for Potentially Inappropriate Medication Use in Older Adults”. Trazodone is not on the list, whereas zolpidem and antipsychotics are.
The Beers Criteria are published following an extensive process of review of the scientific literature. Is this process perfect? Probably not, but when it comes to which medications to be careful about, I think it’s a sounder basis than relying on anecdotes or the experience of individuals.
I will be releasing a podcast episode about the Beer’s criteria later this spring, featuring my UCSF colleague Dr. Michael Steinman, who is part of the AGS Beer’s Criteria expert panel.
I have only just discovered your website and podcast and find them extremely balanced, knowledgeable and helpful. I wish you practiced in NYC! My 88 year-old mom has no significant health issues. She is on HTN medication for labile blood pressure and has primary thrombocytosis and is not taking anything for it at this time. She does suffer from insomnia; she is severely hard-of-hearing (all her life but worse now); and she has arthritis and is very unsteady on her feet. She does physical therapy, walks (as much as she can) with a walker. She has some mild cognitive impairment, mostly forgetting words and having trouble following complex stories. She also suffers from insomnia and depression. Her psychiatrist prescribed Xanax, which she uses very occasionally. So far, she is very resistant to anti-depressants, but if she relents, her psychiatrist recommended amitriptyline. Based on this article, it would seem that you would recommend SSRIs over tricyclics. Can you confirm that SSRIs are less likely to worsen her balance and less likely to worsen her cognitive impairment? These are her chief concerns. I am happy that she sees a psychiatrist, but I am concerned that this psychiatrist may not be up-to-date on psychiatric medications. And will you be doing a podcast or article about geriatric depression? Thanks very much.
Leslie Kernisan, MD MPH says
Thank you for your comments regarding the site and podcast, I’m so glad you find them helpful.
I cannot confirm or specify what is best for your mother’s situation. What I can say is that most expert articles on the management of depression in older adults recommend starting with SSRI-type antidepressants if medication is required, because they are less likely to cause problematic side-effects.
Amitriptyline is an older antidepressant that is quite anticholinergic. Most geriatricians would be very cautious about using it in someone like your mom and would only consider it after trying SSRIs and other options. We would also be extremely cautious about using a medication like Xanax.
If her psychiatrist is recommending these medications, you may want to ask additional questions. What is this provider’s reasoning for recommending amitriptyline rather than an SSRI? Benzodiazepines such as Xanax are known to be risky in older adults, so why does this provider think the likely benefits outweigh the risks?
You could also ask the provider to review and discuss the treatment recommendations outlined in recent review articles, such as these:
Management of Depression in Older Adults: A Review (JAMA 2017)
Depression in the Elderly (NEJM 2014)
Hello, I was taking Gabapentin, 900 mg a day for 4 years for cervical spinal stenosis. I recently discovered it can cause memory issues, which I was having. I am now weaning off of the drug under physician supervision. Will my memory function come back 100%? I honestly thought there was something wrong with my mind, like dementia. I am 54 years old.
Leslie Kernisan, MD MPH says
If you are concerned about your memory, then I would recommend either getting a comprehensive evaluation now, or waiting until you’ve tapered off any memory-affecting medications, and then pursuing more evaluation if you are still experiencing memory issues.
I don’t generally provide clinical care to women of your age. A geriatrician is not ideal for evaluating your memory concerns, because the more likely causes of memory difficulties are different for women in their 50s than women over age 70. You’re at an age when the perimenopausal transition may be playing a role in your symptoms, so you may want to look for a provider who has experience with that. good luck!